CQC report explained · a residential care home
What the CQC found at Cleeve Court Community Resource Centre
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2023
Cleeve Court Community Resource Centre is rated Requires Improvement; care was kind and person-centred, but safety risks and quality checks were not always managed properly.
This was an unannounced inspection on 20 and 29 December 2022. Inspectors spoke with people, relatives and staff, observed care, and checked care records, medicines records, incident reports, recruitment files and quality checks.
People were generally positive about the care. Staff were kind, respectful and available. The home was clean, food was well received, people had access to activities and healthcare, and infection control was handled appropriately during a COVID-19 outbreak.
Inspectors found important weaknesses in safety and management. Risk plans were incomplete or unclear, some monitoring records were not consistent, incidents were not always reviewed, and audits did not ensure that improvements were completed. The overall rating and the ratings for Safe and Well-led were Requires Improvement. Effective, Caring and Responsive were rated Good.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff offering patient, respectful and reassuring support.
“People and relatives all told us the staff were kind and caring.” from the report
Enough staff during inspection
Inspectors saw enough staff available to respond to people promptly. Recruitment checks had been completed safely.
“During our inspection we observed there were enough staff available to respond to people in a timely way.” from the report
Food and mealtimes
People had choices, snacks and drinks. Mealtimes were calm, and staff helped people to eat in a person-centred way.
“We observed mealtimes and found them to be relaxed and unhurried.” from the report
Infection control
The home responded appropriately during a COVID-19 outbreak. Staff used suitable protective equipment and had enough supplies.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Incomplete risk plans
seriousRisks including falls, pressure ulcers, malnutrition, diabetes and wounds were not always assessed or explained clearly enough for staff. This created a risk of avoidable harm.
“People were placed at risk of avoidable harm as the provider had failed to assess and take robust action to mitigate risks to people's safety.” from the report
Weak quality checks
seriousAudits did not reliably identify problems or make sure actions were completed. Some actions from a July 2022 care plan audit were still outstanding in December.
“Governance systems were not robust and effective in identifying areas for improvement.” from the report
Incidents not always followed up
seriousSome accidents and incidents were not added to the provider's system or reviewed by management. This meant lessons were not always learned and some CQC notifications were not made.
“Incidents and accidents had not all been reviewed by management or added to the provider's incident system.” from the report
End of life wishes
needs fixingSome people's end of life wishes were recorded, but there was little information for others. CQC made a recommendation to improve this.
“For other wishes around end of life, there was little information recorded.” from the report
Refresher training
needs fixingSome staff refresher training was overdue against the provider's schedule. The provider said it had plans to address this.
“Some refresher training had fallen behind the provider training schedule.” from the report
- 01What has been done to make sure falls, pressure ulcer, malnutrition and diabetes risks have clear, current care plans?
- 02How are food and fluid records checked to make sure totals, targets and amounts offered or eaten are recorded accurately?
- 03How are wounds treated by community nurses recorded and reviewed in the home's care plans?
- 04How does management now review every accident and incident, and make sure lessons and required notifications are completed?
- 05What progress has been made on the action plan, including the outstanding care plan audit actions and end of life wishes?
This was an unannounced inspection of the newly registered care home covering all five key questions and infection prevention and control; it was the first inspection under the current registration. This explanation was written from the published report of 2 February 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Cleeve Court Community Resource Centre
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- February 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Cleeve Court Community Resource Centre →
- August 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- October 2020
Registered with the Care Quality Commission on 1 October 2020.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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25 live-in carers within about an hour of Bath and North East Somerset
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,030 to £1,320 a week. 20 can care for a couple. 12 years' experience on average.
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Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.